Provider Demographics
NPI:1598031973
Name:SYSOL, SUSAN MARY
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:SYSOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6605 FIRELIGHT LN
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3887
Mailing Address - Country:US
Mailing Address - Phone:770-375-9430
Mailing Address - Fax:
Practice Address - Street 1:650 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30548
Practice Address - Country:US
Practice Address - Phone:678-312-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000266172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker